30429 APPLICANT TO FILL IN INFORMATION WITHII _INES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. �0
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDENTIFICATION
ILDING ADDRESS: 429
SANITARY NO. I APPLICATION SUBMITTAL DAI
er-r,
.�rFRS NAME: L / PHONE CO T ACTOR"NAME: LIC O:
• ✓OC�. <`I 7
OCJ(' f lis A>CeISO/1 Elmo fl f D Q N/C CONTROLq
\RCHITECT/ENGINEER: LIC NO: q If 5 S •�WC / I f��v
CONTACT: PHONE: '{I/• BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CON TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby vrfirm that 1 aft licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
FOQ00 with 8eminn7(KKlpt[Division 3 of Ott Business it Profexlons Cale.sold my license is RESIDENTIAL'
O full force mN effect PERMIT ISSUANCE
mui- Liaenu Cla c� Licq ❑SFDWL D KITCHEN REMODEL
APPLIANCES-RESIDENTIAL PLUMBING
yGi Date — Contra ❑ADDITION DSTRUCTUR L PIPE
ARCHITECTS DECLARATION GMULTI-UNIT GSTRUCTURAI,
Z O y Z 1 understand my plant shall he axil vx public records PANELS
MODIFICATION
OZ— UPTO2W AMPS
F•�FW Licensed Frofesaonul DIMRRVE ❑CHIMNEY REPAIR
�x�• OWNER.BUILDER DECLARATION 201-1008 AMPS IMPROVEMENT
i C W Q I hereby alfirm that 1 tun exempt doom the Cnntmcdor's License Ww for the OVER]"AMPS D BATH REMODEUREPAIR D DEMOLITION
ua3 F following mason.(Section 703 1 5,Business and Po3fessions Codc:Any city or county SIGNS ELECTRICAL D OTHER
y which requires a permit to construct,alter,improve.demolish,m octan any structure
I"'�O� prim it)its issuunce.al.so rcquircs the applicant for such permit o file a signed statement SPECIAL CIRCUTOM ISC.
tvvtyy��� Lha be is licensed pnrsuantIn the pmvldons of the Contractors License Loss(Chapter 9
CpO (commencing with Section7")of Division 3 ofthe Business and Professions Cale)or TEMP.METER OR POLE INST, L
6 that he is exempt thcrcfrvm and[lie basis for the alleged exemption.Any violation at
[I NEW BLDG/ADDITION El DEMOLITION
Section ID.l by any pplicamfor.S permit enbjemetha applicator tnncivil lxnuhy of POWER DEVICES
FZY rl mare than live thprocerf,or my employees
GTENAM FOOD SERVICE
ceS� ❑Lo one larmthe the Immun nryetplended or offered
as'ale(solee,compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
W F•e will da one lark.and the Tao
mreisnottim's Licesoraw,dofor.at apply
1.an ormar of DOTTER
Lm and property
no
Cale:The Conor croon License o Law,dos sol apply s an owner of OUTLETS-SWITCHES-FIXTURES
his own who builds or improves thsuch I and who docs such ware deed of oT through
his own employee,provided!Ilial such Improvements are not intended or offered for NEW NESIDBNTIAL Ii1.ECTR S
sale.IL however,the building or Improvement is sold within one year ofromplemon,the SQ.FT FLOOR AREA $/SQ,CL
maner-builder will have the hurJen of proving that he did on build or improve lin pro,
poseofsale.). /^s _
U 1,as owner of the Perfectly,am exclusively contracting with licemme
ed contmrs to TOTAL: e L•, IT ,
construct the project(See.7044,Business and Professions CaleO The Contractors Li-
cerise Law does not applytoonowner of pmpcny who builds or improves thereon,and QT'. PLUMBING PERMIT FEE UG q
who contracts ets for such projects with a contractor(&)licensed pursuanto the Contractor's fG 'I1n^
Liccme Law. PERMIT ISSUANCE Oslo
❑ m
IaescScc.mp'uma ,B&PCforthisrcemn l.J�+'UI
ALTER-DRAIN&VENT-WATER(EA)
Owner Dane EVALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE
1 hereby affirm under penally of perjury one of the following dedaaions:
❑ I have and will maintain a CcniOcae of Comentto self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND.
Indian,as provided for by Section 37M of the Labor Cole,for the performance of the STORIES TYPL>CONSTRUCTIOI
work for which this permit is issued. FIXTURES-PF.R TRAP
❑I have and will maintain Workers Compensation Inmmnce,as required by Section
3700of the LabaTCed,forthe perfarnwnceofdhe work forwhich this permit is isxual, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Campen.sadion transact,carrier and Policy number are:
Cartier. Policy No.: GAS-F.A.SYSTEMOVER 4(EA) '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
Icss.)
(This—tion sad nm be complde t ifdhe perait is forone hundred dollars($1W) GREASE TRAP BUILDING DIVISION FEES
or
PLANCHECK FEE
Iccnify that in the performance ofthc ware for which this permit is issued. shot[per. SEWER-SANITARY-
mt n Law any person in cony manner an m m bf ora-elsuh' I n Ibe N'nrkccd Conlpen- STORM PA.209 FT.
Z Appli Laws of CaJL'fnmin.Data _0__
ENERGY FEE
� 'L �o WATER HEATIiR WNENTNLECfR GRADING FF.F,
Applicant G ( �'
V) NOTICE TO APPLICANT.IL after makin ix Certificate of Exemption,you should WATER SYSTEM/TREATING
become subject m the Worker's Compensation provisions of the Labor Codc,you must SOILS FEE
forthwith comply with such fooleinns orthi.a permit shall be deenndrevoked WATER SERVICE
a �
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB SQ FT. PAH)
U O 1 hembynffirmlhauhere is. reswetlnn lending agency forthe perlbrntunce of [)am Receiptp
V. E•' the work for which this permit is issued(Sec.3097,Civ.C.)
Lender's Name
U TOTAL
�
W IandelAddress TOTAL:
I certify that I have mad Nis application and state that the above infnrmaion is BUILDING FEE
V) corcct.lIII lm coatilywith-ll city and county mdinances.and start laws ralming to QTY. MECHANICAL PERMIT FEE
UZ building construction,and hereby Offarre representatives of his city to enter upsm the SEISMIC FEE
above-mentioned property for inspection purpmes. t"ERMITn(We)agree m save,indamnity and kep harmlessale City of Cu cardia againstELECIBIC FIiB
liabilities,judgments,costs and expenses which may in any way seems,agait,Isoma City .'n consequence of the gmming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT IO,WCFM)SOURCE REGULATIONS. MECHANICAL FEE
$—f2 /v ER IB.(NMICF.M) CONSTRIICI'ION TA%
Signature OfApphcaMConlmctnr Date T)HAZARDOUS M9'ERIALS DISCLOSURE HOUSING MITIGATION FEE
more oT handle h.mmos material BTU)
as definM by Ne Catarina Municipal Cale.Chapter 9.12,and the Health and Safety
Code,Se,ioo 25532(m)'I HEATING UNIT(OVER 100.000 BTU)
❑Yes Usti,
VF-MILATION FAN(SINGLE RESID) PAID
Will[be applicant or future building occupant use equipment or devices which Date Receipt q
mit hamrdeas air colnamimentsas defined,by the Bay Arca Air Quality Management BOILER-COMP(3HP OR IW.WO BTU)
Dim a? 100.000TOTA
❑tics [I No ROLLER-COMP(OVE100.000BTU)
I have sand he hazardous mmcHe],Iequiremenks under Chapter 6.95 of the Cali- AIR CONDITIONER
brain Ileahh&Safety Cade,Sections 25505,25533 and 25534.I understand thin if Ne ISSUACr DATE
Wilding does not cmeally have a timanl.that it ism bili) Immtif thescem ' NEW RESIDENTIAL MECH. SQ.FT.
yce,ofa Y 5 pan
of the requirements which most be tun prim Io issuance of a CeniOcam or Occupancy. ,
owner or vahon,ed igen Dam n L.
ISSUED BY:
OFFICE